Tag: case studies

The patient is a 31 year old man with a history of intravenous drug use with last reported use nine months previous, who reports low back pain. The patient’s symptoms started as a mild pain and progressively worsened over two weeks to the point that he was unable to stand or ambulate. He also developed intermittent radiation of pain to the bilateral lower extremities and associated symptoms of chills and diaphoresis. Blood cultures were sent. MRI showed an epidural abscess at the level of L5-S1. The patient underwent lumbar spinal decompression surgery, and intra-operative cultures were sent for evaluation.

Serratia marcescens is a motile, facultatively anaerobic, gram negative bacillus of the Enterobacteriaciae family. Some strains of Serratia produce a distinctive brick red pigment, prodigiosin (Image 4), although non pigmented strains are frequently isolated from human infection sites. Serratia marcescens is one of the few Enterobacteriacea that produces DNAse, lipase, and gelatinase. It does not usually ferment lactose. This species is widely present in the environment, including in animals, insects, plants, water, and soil, but unlike other Enterobacteriaciae species it is not a typical component of normal human fecal flora.

Eight species of Serratia have been found to cause infections in humans. Of these, >90% are caused by Serratia marcescens (1). This is a rare cause of infection in immunocompetent hosts but can cause opportunistic nosocomial infections, especially following invasive procedures such as such as intravenous catheterization, respiratory intubation, and urinary tract manipulations. The most common infections caused by Serratia marcescens are urinary tract infections, pneumonia,surgical wound infections, eye infections, and bacteremia. Multiple hospital outbreaks of Serratia have been reported, with sources of infection including tap water, soap, blood transfusion products, and injected medications (2). It has also been described as a cause of endocarditis in injection drug users (3).

Serratia is intrinsically resistant to ampicillin, ampicillin-sulbactam, and 1st and 2nd generation cephalosporins due to an inducible, chromosomal AmpC beta-lactamase. Resistance to later-generation cephalosporins may be induced through exposure to these antibiotics, despite not being detected on initial antibiotic susceptibility tests. Thus, susceptibility testing is misleading and thirdgeneration cephalosporins (such as ceftazidime, ceftriaxone, and cefpodoxime) should be avoided for the treatment of Serratia species regardless of in vitro susceptibility.

A 54 year old male presented in the emergency room with worsening of shortness of breath and chest pain. He has a history of a bicuspid aortic valve that was treated with bio-prosthetic aortic valve replacement seventeen years ago and a second aortic valve replacement seven years ago. The patient’s echocardiogram showed severe aorticstenosis and moderate to severe mitral regurgitation. During hospital stay he started to show signs of low cardiac output syndrome and an intra-aortic balloon pump was placed. During sternotomy for aortic valve replacement and mitral valve repair they discovered a severely calcified and stenotic valve with additional debris that could be consistent with endocarditis. Tissue culture was sent.

Gram stain showed pink strings that could be gram negative rods, but could also be tissue debris due to tissue grinding (Image 1). After 3 days of incubation, some colonies grew on 5% sheep blood (Image 2) and chocolate agar plates with no growth on MacConkey selective medium.

Colony Gram stain made from these colonies (Image 3) was compared with the initial gram stain and showed similar type of pleomorphic gram negative rods. MALDI-TOF identified this organism as Cardiobacterium hominis.

Cardiobacterium hominis is a fastidious, pleomorphic, non-motile, gram negative bacillus and member of the HACEK group which comprises Haemophilus species, Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae. C. hominis is present as normal flora of the oropharynx in most individuals but it has also been attributed to cause infective endocarditis.

C hominis is a fastidious bacterium that grows best in the presence of increased levels of CO2 and high levels of humidity and often takes several days to grow on solid media (1). It can be distinguished from other HACEK members by a positive oxidase reaction, the production of indole and the absence of catalase activity and nitrate production.

Some of the risk factors leading to C hominis endocarditis include dental work, structural cardiac abnormalities, previous valve replacement, dilated cardiomyopathy and past history of rheumatic heart disease and endocarditis (2). The illness usually follows a sub acute course with symptoms lasting for weeks or months (1). Patients will often report fever, myalgia, anorexia, and weight loss. C. hominis tends to form large, friable vegetations associated with cerebral embolization or mycotic aneurysm formation and this might be responsible for atypical presentation of endocarditis(1). The overall prognosis of endocarditis due to C. hominis is quite favorable, despite the frequent need fo rvalve replacement (3).

Third generation cephalosporin (ceftriaxone) is considered the drug of choice for C. hominis endocarditis. Ampicillin can be used after susceptibility testing. Ampicillin-sulbactam or ciprofloxacin are alternative therapeutic options.

A 23 year old man presented to the hospital with recurrent fever up to 103F with associated nausea and vomiting, epistaxis, watery diarrhea, dyspnea, and decreased appetite for several days. Blood cultures from admission were positive for MSSA and a stool PCR was positive for Vibrio species. He was admitted and treated for sepsis. His CBC demonstrated a marked pancytopenia ( WBC count 0.6 K/μL) and the hematopathology team was consulted to review the peripheral blood film.

Peripheral blood smear.

Review of the peripheral blood confirmed a markedly pancytopenic picture with virtually no leukocytes in the region of best RBC “spread” (Image 1A). In the periphery of the smear (1B and C) clusters of leukocytes were noted where left-shifted granulocytes were seen. Many demonstrated nuclear irregularity and abnormal granulation (B) and some showed the presence of numerous Auer rods (Image 1C, arrows).

The presence of abnormally granulated immature neutrophilic precursors, and cells with numerous Auer rods was morphologically compatible with acute promyelocytic leukemia (APL) and a rush preliminary diagnosis was rendered. The patient was started on ATRA therapy and FISH for PML-RARA was expedited.

Discussion

Acute promyelocyticleukemia (APL) is characterized as an acute myeloid leukemia in which promyelocytes with the PML-RARA fusion predominate. The PML-RARA fusion is the result of a balanced translocation between chromosomes 15 and 17, designated ast (15;17)(q24.1;q21.2). The promyelocyte progenitor cell is the cell of origin of APL. APL occurs most frequently in middle aged individuals, but can occur at any age.

The first account of APL was originally discussed in the late 1950s in which L. K.Hillestad, a hematologist from Norway, described a disorder as “a white blood cell picture dominated by promyelocytes and severe bleeding caused mainly by fibrinolysis.” The gene fusion was elucidated in the late 1970s at the University of Chicago demonstrating the balanced translocation between chromosomes 15 and 17. Cure rates at that time were still very low, until in the mid 1980s when researchers in China demonstrated the use of all-trans retinoic acid causing complete remission in APL patients.

Two distinct subtypes of APL exist: hypergranular (typical) or microgranular. The hypergranular variant is filled with large Auer rods and with dense cytoplasmic granules that can obstruct the nucleus. In contrast, the microgranular variant has a scantiness of cytoplasmic granules or small azurophilic granules.

The immunophenotype for APL is quite distinct and characterized by low or absent expression of CD34 and HLA-DR (in keeping with the cellular differentiation from blast to promyelocyte). APL cells are positive CD33 and CD13 with most cases showing expression of CD117 (sometimes weak). APL cells are usually negative for CD15, CD65, CD11a, CD11b, and CD18. The microgranular variant may display positive staining for CD34 and CD2. For both variants, IHC with antibodies to the PML gene demonstrates a nuclear multi granular pattern with nucleolar exclusion, a finding that is unique to APL and not seen in AML or normal promyelocyte morphology.

The main clinical symptom of APL is hemorrhagic, including gingival bleeding and ecchymosis but can progress to disseminated intravascular coagulopathy (DIC). Other symptoms of APL include those related to pancytopenia, including weakness, fatigue, and infections.

The prognosis for APL is considered to be excellent. Tretinoin (ATRA) interacts with the PML-RARA fusion product allowing for maturation and differentiation to occur along the granulocytic lineage, eliminating the promyelocyte population. Combination therapy with tretinoin and arsenic trioxide has become the gold standard of care leading to excellent remission rates.

Swerdlow,Steven H. WHO Classification of Tumours of Haematopoietic and LymphoidTissues. International Agency for Research on Cancer, 2017.

-Christopher Felicelli is an M3 at Loyola University Chicago Stritch School of Medicine. Follow Chris on Twitter at @ChrisFelicelli

-Kamran M. Mirza, MD PhD is an Assistant Professor of Pathology and Medical Director of Molecular Pathology at Loyola University Medical Center. He was a top 5 honoree in ASCP’s Forty Under 40 2017. Follow Dr. Mirza on twitter @kmirza.

The patient is a 21 year old male with a history of developmental delay and chronic kidney disease secondary to posterior urethral valves, status post kidney transplant at age 14, who presents for a routine office visit with his pediatric nephrologist. In the past year, he has had chronic antibody-mediated transplant rejection despite immunosuppression. In addition, he drinks 1-1.5 gallons of water daily, self-catheterizes every three hours, and has an indwelling Foley at night. During the office visit, he denies any urinary symptoms, including dysuria, hematuria, cloudy urine, reduced output, or fever. However, given his significant risk factors for urinary tract infection, his provider orders a urinalysis and urine culture.

Laboratory Identification

The urine was noted to be cloudy, was positive for nitrites and leukocyte esterase, and had 11-50 white blood cells per high-powered field.

Urine culture demonstrated the growth of two organisms, one of which was identified to be greater than 100,000 CFU of Proteus miribalis, and the second of which grew 10,000-100,000 CFU, was isolated, and is shown below:

Mass spectrometry by MALDI-TOF confirmed that this second organism is Streptococcus pneumoniae, a bile-soluble gram positive diplococci.

Discussion

S pneumoniae is implicated in a number of diseases, but it is an uncommon pathogen in the urine. Several case-series and case reports have been published demonstrating a predilection of pathogenic urinary S pneumoniae for pediatric patients with urinary tract abnormalities. In one series, 26 urine cultures from 18 patients were identified as growing S pneumoniae, with CFU counts ranging from 100 to 100,000. Sixteen of the 26 cultures grew only S pneumoniae. Of the 18 patients, only six were adults, eight had had a kidney transplant, and four others had chronic problems with their kidneys (1). In another series of three pediatric cases, one patient had congenital bilateral duplication of the renal collecting system, one had a “congenital imperforate anus (high type 1A) with a rectovesical fistula and grade 4 bilateral vesicoureteral reflux,” and the third had bilateral renal dysplasia (2). Neither case series was able to identify a specific serotype of S pneumoniae responsible for these infections.

As discussed by Choi et al, the altered flow dynamics of the abnormal urinary systems in these patients may be compromising normal host immune clearance mechanisms, thereby increasing the susceptibility to infection (2, 3). However, it is unclear why S pneumoniae infections have a predilection for congenital urinary tract abnormalities, as opposed to all urinary tract abnormalities. Choi et al postulate that some of the gene polymorphisms known to predispose individuals to UTI or pneumococcal infections could be genetically linked to genes responsible for urinary tract abnormalities, thus increasing the probability that an individual with a congenital urinary tract abnormality would have an S pneumoniae urinary tract infection (2,4).

Given the patient’s history and risk factors, the presence of S pneumoniae in his urine was found to be significant. Treatment of both organisms and appropriate follow-up was recommended.

The patient is a 54 year old woman who presented to the hospital after a fall, which revealed a pathologic fracture of T1 and a spinal lesion from C6/C7 to T2. CT of the chest/abdomen and pelvis at the time showed a large mass in the anterior mediastinum with extensive lymphadenopathy and lytic lesions in the spine and ribs.

C7-T1 Soft Tissue Excision

H&E 20XH&E 50XH&E 100XCD30BSAP/PAX5KI-67

Diagnosis

Sections show sheets of large epithelioid-like cells with segmented nuclei with variably prominent nucleoli and ample amounts of eosinophilic cytoplasm.A majority of these larger cells have abundant cytoplasm and lobulated nucle iwith multiple nucleoli and a surrounding halo. They are consistent with Lacunar cells. These cells form large aggregates and are admixed with numerous neutrophils, histiocytes and scattered lymphocytes.

Immunohistochemical staining revealed that the largea typical cells are immunoreactive for CD30, CD15 and PAX5/BSAP. CD45 highlighted background lymphocytes but showed infrequent dim staining in the large atypical cells. By Ki-67, the proliferation index is 50-60% in the large atypical cells. Taken together, the findings are consistent with Classic Hodgkin Lymphoma, nodular sclerosis, syncytial variant.

Discussion

Classic Hodgkin lymphoma (CHL) has four distinct subtypes including nodular sclerosis, lymphocyte-rich, mixed cellularity and lymphocyte-depleted. These subtypes differ based on characteristics of the background non-neopalastic reactive cells and the histomorphology of the Hodgkin/Reed-Sternberg cells (HRS). Nodular sclerosis Classic Hodgkin lymphoma accounts (NSCHL) for approximately 70% of all CHLs. The mediastinum is the most commonly involved site and it generally occurs in people between the ages of 15-34 years old. Generally, the histology shows nodules with surrounding fibrosis. There are a variable number of Hodgkin/Reed-Sternberg (HRS) cells mixed with other inflammatory cells. The characteristic HRS cell is called a lacunar cell. This is a type of HRS cell with more cytoplasm, less prominent nucleoli and can show retraction of the cytoplasm in formalin-fixed tissue that gives the cell a halo or “lacunae.”1

The syncytial variant (SV) of CHL, nodular sclerosis was first described in the 1980s. It presents in 5-15% of cases of NS CHL. It is characterized by sheets and clusters of “lacunar cells” typical of the type of HRS cell most commonly seen in NS CHL. Previous studies had determined the SV of CHL to have a worse prognosis and more aggressive course than other subgroups. In a more recent study by Sethi, et. al. the clinical features and response to treatment of patients with SV were compared to patients with typical NS CHL. Within the cohort, 43 patients with SV were compared to 124 patients with typical NS CHL. The study found that there was no significant difference in age, sex, performance status, stage, bulky disease, number of nodal sites and chemotherapy regimens used between the two groups.2

As far as treatment outcomes, the rate of complete response in the SV group was 74% vs. 87% in the NS group. This result approached statistical significance with a p=0.05. The medium progression-free survival in the SV group was significantly shorter compared with the NS group. The overall survival, however was not statistically different, indicating that salvage chemotherapy was ultimately able to match the clinical outcomes for patients with SV type to patients with NS type. 2

Currently, all CHLs are treated with adriamycin, bleomycin,vinblastine, decarbazine (ABVD) chemotherapy regimen plus or minus radiation therapy regardless of subtype. Patients with relapsed or refractory disease are treated with a “salvage” chemotherapy regimen followed by an autologous stem cell transplant. Emerging therapies including PD-1 inhibitor nivolumab have shown great effect in patients with CHL. PD-1 or programmed death ligand 1 is overexpressed on HRS cells. This ligand binds with receptorson T-cells to prevent the T-cell immune response and reduce cytokine activation and targeted response against the proliferating HRS cells. By using an antibody against the PD-1 ligand in CHL,the ability of the tumor to suppress the immune response is decreased and patients have been shown to have better clinical response rates.3

Patients with SV do need to be recognized as a distinct subgroup that may have a higher risk of disease progression with first line chemotherapy agents. Due to the high numbers of HRS cells seen in patients with SV and the increased failure rate of initial chemotherapy agents, antibody therapies such as PD-1 inhibitors may be even more successful in those patients.

–Chelsea Marcus, MD is a third year resident in anatomic and clinical pathology at Beth Israel Deaconess Medical Center in Boston, MA and will be starting her fellowship in Hematopathology at BIDMC in July. She has a particular interest in High-grade B-Cell lymphomas and the genetic alterations of these lymphomas.

A 44 year old male presented to the emergency department with severe, throbbing back pain in his mid-thoracic spine. He states the pain began a couple weeks ago and noted no recent fevers or night sweats, but does admit to chills. His past medical history is significant for end stage renal disease requiring dialysis, insulin dependent diabetes mellitus, and multiple amputations. On physical examination, there was tenderness to palpation along spine in mid-thoracic region. Lab work showed a normal white blood cell count, C reactive protein of 0.90 mg/dL (0.00 – 0.50 mg/dL), and an erythrocyte sedimentation rate of 60.0 mm/hr (0.0 -10.0 mm/hr). MRI of the spine was consistent with discitis and osteomyelitis at T7-8 with compression fractures causing spinal stenosis and cord compression. Given the concern for an infection process, blood cultures were collected and interventional radiology performed a bone biopsy. The specimen was sent for bacterial, fungal, and AFB cultures as well as for histology.

The organism grew as discrete, creamy colonies growing on blood agar and Sabouraud dextrose agar after 48 hours of incubation at 35°C and resembled a yeast. MALDI-TOF mass spectrometry identified the isolate as Candida parapsilosis. Similarly, the surgical pathology specimen showed necrotic bone with inflammation and yeast forms and pseudohyphae consistent with a Candida spp. infection. Blood cultures were negative. On chart review from an outside hospital, it was discovered the patient had an episode of candidemia ten months ago which was thought to be related to his dialysis port.

Discussion

Yeasts are ubiquitous in the environment and make up the normal microbiota of human skin as well as the oral cavity, gastrointestinal tract and genitourinary tract. In general, when Candida spp. cause infections it is thought to an opportunistic infection acquired endogenously and due to exposure to prolonged antibiotics, suppressed immune system, or as a result of intravascular catheters. Those with diabetes mellitus, mucositis, bowel perforations, and intravenous drug users are most susceptible. Infections with Candida parapsilosis are becoming more common, and have the potential to cause invasive disease, such as fungal endocarditis and severe infections in the neonatal population.

In the microbiology laboratory, C. parapsilosis grows rapidly as discrete, creamy colonies on a variety of agars. On cornmeal-Tween 80 agar, C. parapsilosis grows as short, curved pseudohyphae with blastoconidia arranged singly or in small clusters at points of constriction. The arrangement is sometimes described as resembling a sage bush. C. parapsilosis is germ tube negative and is negative for urease. In many laboratories currently, identification is achieved by automated methods, such as Vitek 2, or mass spectrometry, allowing for more rapid and accurate identification.

Anti-fungals, such as echinocandins, azoles, and amphotericin B, are all potential therapeutic options to treat C. parapsilosis infections. CLSI C.parapsilosis specific breakpoints exist for fluconazole, voriconazole,micafungin, caspofungin, and anidulafungin in the M27-S4. Susceptibility testing should be performed on significant isolates from normally sterile sites.

In the case of our patient, infectious disease was consulted and he was started on IV micafungin and then transitioned to oral fluconazole. He had a transesophgeal echo and eye exam performed to ensure he didn’t have endocarditis or an invasive eye infection due to hematogenous spread of the yeast. He was discharged home on long term oral fluconazole.

-Rim Alkawas, MD, is a second year Anatomic and Clinical Pathology resident at the University of Mississippi Medical Center.

-Lisa Stempak, MD, is an Assistant Professor of Pathology at the University of Mississippi Medical Center in Jackson, MS. She is certified by the American Board of Pathology in Anatomic and Clinical Pathology as well as Medical Microbiology. She is the Director of Clinical Pathology as well as the Microbiology and Serology Laboratories. Her interests include infectious disease histology, process and quality improvement, and resident education.

A young adult female presents to an urgent care clinic with the chief complaint of a “bump and surrounding redness” on her right medial thigh. The patient reports the bump had been present without change for 1 year. Approximately 2 days prior to presenting at the urgent care clinic the patient states she nicked the bump while shaving, and subsequently the bump became tender with surrounding erythema and produced purulent drainage. The patient denies any similar prior lesions and denies any significant past medical history. On physical exam, the lesion measured 1 cm with the surrounding erythema measuring 5cm. The urgent care physician performed an incision and drainage and noted a scant amount of white purulent material within the lesion. A cyst wall was identified and was removed as much as possible. A swab of the purulent material was collected and submitted to microbiology for culture.

Laboratory Identification

The primary gram smear of the swab specimen was interpreted as no bacteria or polys seen. Routine culture media including blood, chocolate, MacConkey, and CNA agar were inoculated and incubated aerobically. Following incubation, the blood agar showed few gram positive cocci consistent with usual skin flora and few single morphology of medium to large sized gray colonies without hemolysis. On the MacConkey agar, few single morphology non-lactose fermenting colonies were identified. The gray colonies identified on the blood agar gram stained as gram negative bacilli with unremarkable morphology. An oxidase test was performed and the bacteria was found to be oxidase positive. The key biochemical and physiologic characteristics of the isolate included: good growth on thiosulfate citrate bile salts and sucrose (TCBS) agar with yellow colonies, good growth in 6% NaCl nutrient broth, and no growth in 0% NaCl nutrient broth. The organism was identified by matrix-assisted laser desorption/ionization time of flight (MALDI-TOF) as Vibrio alginolyticus.

Image 1. Blood agar isolate of medium sized gray colonies.

Image 2. MacConkey agar with non-lactose fermenting colonies.

Discussion

Vibrio spp. are water organisms commonly found in marine or brackish water environments. These organisms are gram negative bacilli which classically have “comma” shaped morphology on gram smear, though this is not an absolute. On sheep blood agar, these organisms are variably beta hemolytic medium to large gray colonies and on MacConkey agar are non-lactose fermenting (with the exception of Vibrio vulnificus). Vibrio spp. are oxidase positive, ferment glucose, and readily grow on most isolation media with growth being enhanced with the addition of 1% NaCl to the media. The growth characteristics on media containing different concentrations of NaCl can be used in differentiating the different Vibrio spp. Thiosulfate Citrate Bile Salts and Sucrose (TCBS) agar is both selective and differential for Vibrio spp. with sucrose fermentation being detected as yellow colony formation.

Vibrio angiolyticus typically causes extraintestinal infections, with wound infections and otitis externa being the most frequent. Transmission frequently occurs via traumatic aquatic injuries in contaminated water. Vibrio angiolyticus rarely causes intestinal disease and is isolated in less than 5% of stool cultures in patients with Vibrio associated diarrhea. Growth characteristics of Vibrio alginolyticus include yellow colonies on TCBS due to its ability to ferment sucrose and good growth on 6% NaCl and no growth on 0% NaCl. Additional key biochemical characteristics of Vibrio alginolyticus include oxidase positivity, nitrite positivity, negative for myo-Inositol fermentation, negative for arginine dihydrolase, positive for lysine decarboxylase, and variable positivity for ornithine decarboxylase. Most wound infections due to Vibrio alginolyticus are non-severe, and most mild infections will clear without antibiotic therapy.